The Acute Management of Pelvic Ring Injuries - Sean E. Nork, MD Harborview Medical Center - Orthopaedic Trauma ...
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The Acute Management of Pelvic
Ring Injuries
Sean E. Nork, MD
Harborview Medical Center
Original Author: Kyle F. Dickson, MD; Created March 2004
New Author: Sean E. Nork, MD; Revised January 2007
Revised: December 2010
Pelvic Ring Injuries High energy Morbidity/Mortality Hemorrhage
Pelvic Ring Injuries
An unstable pelvic injury may
allow hemorrhage to collect
in the true pelvis as there is
no longer a constraint
which allows tamponade.
The volume was traditionally
assume to be a cylinder
with a volume of 4/3π r3,
However…
Best estimated by a hemi-elliptical sphere
(Stover et al, J Trauma, 2006)
Primary survey: ABC’s
Airway maintenance with cervical spine
protection
Breathing and ventilation
Circulation with hemorrhage control
Disability: Neurologic status
Exposure/environment control: undress
patient but prevent hypothemia
Considerations for Transfer or Care at a Specialized Center:
Pelvic Fractures
• Significant posterior pelvis instability/displacement on the initial AP
X-ray (indicates potential need for ORIF)
• Bladder/urethra injury
• Open pelvic fractures
• Lateral directed force with fractures through iliac wing, sacral ala or
foramina
• Open book with anterior displacement > 2.5 cm (value of 2.5
centimeters somewhat arbitrary and controversial with regards to
reliability)
Physical Exam • Degloving injuries • Limb shortening • Limb rotation • Open wounds • Swelling &
Defining Pelvic Stability??? • Radiographic • Hemodynamic • Biomechanical (Tile & Hearn) • Mechanical “Able to withstand normal physiological forces without abnormal deformation”
Stable or Unstable? • Single examiner • Use fluoro if available • Best in experienced hands
Radiographic Signs of Instability • Sacroiliac displacement of 5 mm in any plane • Posterior fracture gap (rather than impaction) • Avulsion of fifth lumbar transverse process, lateral border of sacrum (sacrotuberous ligament), or ischial spine (sacrospinous ligament)
Open Pelvic Injuries • Open wounds extending to the colon, rectum, or perineum: strongly consider early diverting colostomy • Soft-tissue wounds should be aggressively debrided • Early repair of vaginal lacerations to minimize subsequent pelvic abscess
Urologic Injuries • 15% incidence • Blood at meatus or high riding prostate • Eventual swelling of scrotum and labia (occasional arterial bleeder requiring surgery) • Retrograde urethrogram indicated in pelvic injured patients
Urologic Injuries • Intraperitoneal & extraperitoneal bladder ruptures are usually repaired • A foley catheter is preferred • If a supra-pubic catheter it used, it should be tunneled to prevent anterior wound contamination • Urethral injuries are usually repaired on a delayed basis
Sources of Hemorrhage
• External (open
wounds)
• Internal: Chest
• Long
bones
• Abdominal
•
RetroperitonealSources of Hemorrhage
• External (open
wounds)
Chest x-ray
Physical exam, swelling
• Internal: Chest DPL, ultrasound, FAST
• Long
CT scan, direct look
bones
• Abdominal
•
RetroperitonealShock vs Hemodynamic
Instability
• Definitions Confusing
• Potentially based on multiple factors &
measures
• Lactate
• Base Deficit
• SBP < 90 mmHg
• Ongoing drop in HematrocritPelvic Fractures & Hemorrhage
• Fracture pattern associated with risk of vascular injury (Young & Burgess)
• External rotation and vertical shear injury patterns at
higher risk for a vascular injury that internal rotation
patterns
• APC & VS (antero-posterior compression and vertical shear) at increased
risk of hemorrhage
• Injury patterns that are tensile to N-V structures at increased risk
• (eg iliac wing fractures with GSN extension
Dalal et al, JT, 1989
Burgess et al, JT, 1990
Whitbeck et al, JOT, 1997
Switzer et al, JOT, 2000
Eastridge et al, JT, 2002Pelvic Fractures & Hemorrhage:
Young and Burgess Classification
Lateral
Compression
(LC)
Anteroposterior
Compression
(APC)
V
eased
Vertical Shear
(VS)Hemorrhage Control: Methods
• Pelvic
Containment
• Sheet
• Pelvic Binder
• External
Fixation
• Angiography
• LaparotomyCircumferential Sheeting
• Supine 2
1
• 2 “Wrappers”
• Placement
• Apply
• “Clamper” 4 3
• 30 Seconds
Routt et al, JOT, 2002Sheet Application
Sheet Application
BeforeAfter
Pelvic Binders
Commercially available.
Placed over the
TROCHANTERS and not
over the abdomen.External Fixation • Location Clinical Application AIIS Resuscitative ASIS Augmentative C-clamp Definitive
Biomechanics of External Fixation: Anterior
External Fixation
• Open book injuries with posterior ligaments
(hinge) intact:
•
• All designs work
C-type injury patterns
No designs work well (but AIIS frames help more
than ASIS frames)Biomechanics of External Fixation:
Considerations
• Pin size
• Number of pins
• Frame design
• Frame locationAS Frames • Placed at the iliac crests bilaterally • Not a good vector for controlling the pelvis
AI
• Placed at the AIIS
bilaterally
• At least biomechanically
equivalent, thought to be
superior to ASIS frames
• Patients can sit
Kim et al, CORR, 1999AIIS Frames
Placed at the AIIS
bilaterally
At least biomechanically
equivalent, thought to
be superior to ASIS
frames
Patients can sit
Kim et al, CORR, 1999Indications for External Fixation
• Resuscitative (hemorrhage control,
stability)
• To decrease pain in
polytraumatized patients?
• As an adjunct to ORIF
• Definitive treatment (Rare!)
• Distraction frame
• Can’t ORIF the pelvisIndications for External Fixation
• Resuscitative (hemorrhage control,
stability)
• To decrease pain in
polytraumatized patients?
• As an adjunct to ORIF
• Definitive treatment (Rare!)
• Distraction frame
• Can’t ORIF the pelvisIndications for External Fixation
• Resuscitative (hemorrhage control,
stability)
Theoretical and a
• To decrease pain in marginal indication,
polytraumatized patients? but there is literature
support
• As an adjunct to ORIF
• Definitive treatment (Rare!) Barei, D. P.; Shafer, B. L.; Beingessner, D.
M.; Gardner, M. J.; Nork, S. E.; and Routt,
• Distraction frame M. L.: The impact of open reduction internal
• Can’t ORIF the pelvis fixation on acute pain management in unstable
pelvic ring injuries. J Trauma, 68(4): 949-53,
2010.Indications for External Fixation
• Resuscitative (hemorrhage control,
stability)
• To decrease pain in
polytraumatized patients?
• As an adjunct to ORIF
• Definitive treatment (Rare!)
• Distraction frame
• Can’t ORIF the pelvisIndications for External Fixation
• Resuscitative (hemorrhage contr ol,
stability)
• To decrease pain in
polytraumatized patients?
• As an adjunct to ORIF
• Definitive treatment (Rare!)
• Distraction frame
• If can’t ORIF the pelvisTechnical Details: ASIS & AIIS Frames
Pin Orientation: ASIS
Pin Orientation: AIIS
Pin Orientations
Technical Details: ASIS
• Fluoro dependent
frames…
• 3 to 5 cm posterior to the ASIS
• Along the gluteus medius pillar
• Incisions directed toward the
anticipated final pin location
• Pin entry at the junction of the lateral
2/3 and medial 1/3 of the iliac crest
(lateral overhang of the crest)
• Aim: 30 to 45
degrees (from lateral to
• medial)
Toward the hip joint
Consider partial closed reduction first!Outlet Oblique Image • Inner Table • Outer Table • ASIS
Outlet Oblique Image • Inner Table • Outer Table • ASIS
Confirm Pin Placement
Technical Details: AIIS
frames…
• Fluoro dependent:
• 1. 30/30 outlet/obturator obl ique
(confirm entry location and directi on)
• 2. Iliac oblique (confirm dir ection
above sciatic notch)
• 3. Inlet/obturator oblique (c onfirm
depth)
• Incisions directed toward t he
anticipated final location
• Blunt dissection
• Aim: According to
fluoro
Consider partial closed reduction first!• Outlet Obturator Oblique Image
Outlet Obturator Oblique Image5 degrees too much obturator 5 degrees too little obturator 5 degrees too much outlet 5 degrees too little outlet
5 degrees too much obturator 5 degrees too little obturator 5 degrees too much outlet 5 degrees too little outlet
JUDITH H.M.C. #6
DR. NORK
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13:32:44
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JUDITH H.M.C. #6
HUEY DR. NORK
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#0021
kU 71
mR 8.0
Xt 3.45
PEL 2689320
kU 70
mR 8.0
Xt 3.55
PEL 2689320 ZIEHM• Iliac Oblique Image
Inlet Obturator Oblique Image
Outlet Obturator Oblique Image
Pin Orientation Inlet (with obturator oblique)
Pin Orientation Inlet (with obturator oblique)
Anti-shock Clamp (C-clamp)
Better posterior pelvis
stabilization
Allows abdominal access
Consider application with
fluoro or in the OR to
prevent poor pin placement
Can be combined with pelvic
packing
Ertel, W et al, JOT, 2001Anti-shock Clamp (C-clamp) Better posterior pelvis stabilization Allows abdominal access Consider application with fluoro or in the OR to prevent poor pin placement Can be combined with pelvic packing
Anti-shock Clamp (C-clamp) Better posterior pelvis stabilization Allows abdominal access Consider application with fluoro or in the OR to prevent poor pin placement Can be combined with pelvic packing
Anti-shock Clamp (C-clamp) Better posterior pelvis stabilization Allows abdominal access Consider application with fluoro or in the OR to prevent poor pin placement Can be combined with pelvic packing
Emergent Application
C-clamp: Anatomical
Landmarks
• Same (similar location) as the starting
point for an iliosacral screw
Pin Location
• “Groove” located on the lateral ilium as
the wing becomes the posterior pelvis
• Allows for maximum compression
Near IS screw entry point
• Can be identified without fluoro in
experienced hands
Pohlemann et al, JOT, 2004Caution…
Avoid Over-compression in
Sacral Fractures!Pelvic Packing
• Ertel, W et al, JOT, 2001
• Pohlemann et al, Giannoudis et al,Role of Angiography??? • Valuable for arterial only • Estimated at 5-15% • Timing (early vs late?) • Institution dependent
Role of Angiography???
• Fracture pattern may
predict effectiveness
• Contrast CT suggests
• Effective in retrospective
studies!!!Vascular Injuries
• Arterial vs Venous vs
Cancellous
• Unstable posterior ring
association
• Associated fracture
extension into notch
• Role of angiography
Cryer et al, JT, 1988
O’Neill et al, CORR, 1996
Goldstein et al, JT, 1994Acute Hemipelvectomy….
Acute Hemipelvectomy….
Rarely required (thankfully)
Life saving indications onlyAcute Hemipelvectomy….
Retrospective evidence
• Hypotensivesuwgitghestsatbsle…pelvicpattern…
• Proceed to Laparotomy (85% with abdominal hemorrhage)
• Hypotensive with unstable pelvic pattern…
• Proceed to Angio (59% with pEoasstirtiidvgeeaentgali,oJ)T,2002
Contrast enhanced CT very suggestive of arterial source
(40 fold likelihood ratio)
(PPV and NPV of 80%, 98%)
Stephen et al, JT, 1999Example of a protocol for management
Example of a protocol for management
• Hypovolemic shock and no response to fluids…
• (+) DPL: 1. Laparotomy (+/- packing with ex fix)
• 2. Angio
• (-) DPL: 1. Sheet/binder/ex-fix (some still crash lap)
• 2. Angio
Hypovolemic shock with response to fluids…
(++) DPL: 1. Laparotomy (+/- packing with ex fix)
2. Ex Fix
3. Angio
(+) DPL: 1. Ex Fix
2. Laparotomy
3. Angio
(-) DPL: 1. Sheet/binder
2. Angio
3. Ex FixExample of a protocol for management
Protocol for Management
• Biffl et al, Evolution of a mutlidisciplinary clinical pathway for the
management of unstable patients with pelvic fractures. JOT, 2001
5 elements: Immediate trauma surgeon availability (+ Ortho!)
Early simultaneous blood and coagulation products
Prompt diagnosis & treatment of life threatening injuries
Stabilization of the pelvic girdle
Timely pelvic angiography and embolization
Changes: Patients more severely injured (52% vs 35% SBP < 90)
DPL phased out for U/S
Pelvic binders and C-clamps replaced traditional ex fixProtocol for Management • Biffl et al, Evolution of a mutlidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. JOT, 2001 Mortality decreased from 31% to 15% Exsanguination death from 9% to 1% MOF from 12% to 1% Death (
Immediate Percutaneous Fixation
• From Chip Routt, MDSummary: Acute Management
• Play well with others (general surgery,
urology, interventional radiology,
neurosurgery)
• Understand the fracture pattern
• Do something (sheet, binder, ex fix, c-clamp)
• Combine knowledge of the fracture, the patients
condition, and the physical exam to decide on the
next stepThank You
Sean E. Nork, MD
Harborview Medical Center
University of Washington
HMC Faculty
Barei, Beingessner, Bellabarba, Benirschke, Chapman, Dunbar, Hanel,
Hanson, Henley, Krieg, Routt, Sangeorzan, Smith, TaitsmanAcknowledgment
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